Aerosol therapy during mechanical ventilation: an international survey

Purpose

To describe the practice, knowledge and beliefs about aerosol therapy during mechanical ventilation in an international sample of physicians working in intensive care units (ICU).

Methods

A self-administered survey was emailed to physicians who worked regularly in ICUs. The physicians were identified from the databases of the European and French societies of intensive care medicine and the REVA network.

Results

Of the 1,192 responses (15 % response rate), 854 were analyzed. Of the respondents, who represented 611 departments in 70 countries, 99 % reported using aerosol therapy during mechanical ventilation (including non-invasive), 43 % exclusively used nebulizers and 55 % also used metered dose inhalers. Nebulization relied on jet, ultrasonic and vibrating mesh nebulizers (55 %, 44 % and 14 % of respondents, respectively). Bronchodilators and steroids were the most frequently delivered drugs, and 80 % of respondents had a positive opinion concerning nebulized colistin and 30 % reported the use of nebulized antibiotics at least every other month. During nebulization, ventilator settings were never changed by 77 % of respondents, 65 % reported placing a filter on the expiratory limb, and of these 28 % never changed it. Only 22 % of respondents using heated humidifiers reported turning them off during nebulization. Specific knowledge about droplet size and nebulization yield was poor. A majority of respondents (87 %) thought that ultrasonic nebulizers outperform jet nebulizers, while 69 % had no opinion concerning mesh nebulizers.

Conclusions

Aerosol therapy during mechanical ventilation is used by over 95 % of intensivists, mostly for bronchodilator and steroid administration, but also frequently for antibiotics. The current scientific knowledge about optimal implementation seemed infrequently applied, suggesting the need for educational programs and research focusing on a better bench-to-bedside transfer of knowledge.     

Exergames for motor rehabilitation in older adults: an umbrella review

Background: Exergames have been used as an innovative motor rehabilitation method with the main aim of improving motivation and exercise. As research interest in exergaming for rehabilitation is rapidly growing, a review of existing systematic reviews is important to synthesize the available evidence and provide recommendations.

Objectives: In this article, we systematically synthesized the information from reviews that have examined the effects if exergames on different body movement parameters in older adults with and without specific pathologies.

Method: Searches were conducted in Web of Science, Scopus, PsycARTICLES, PsycINFO, Psychology and Behavioural Sciences Collection, PubMed, SciELO, B-On and Google Scholar, articulating different terms and Boolean operators. Systematic reviews, meta-analysis and literature reviews published until May 2017 that investigated exergame interventions on physical outcomes, such as balance, gait, limb movements, muscle strength, in healthy and non-healthy older adults.

Results: Based on prior reviews, exergaming, as a standalone intervention, has a positive effect on balance, gait, muscle strength, upper limb function, and dexterity. When compared to traditional physiotherapy, exergaming has at least similar effects on these outcomes. Many of the investigated studies indicated low methodological quality for the evaluation of the effects of exergames on different outcomes related to motor rehabilitation.

Conclusions: Exergames could be used as a complement to traditional forms of motor rehabilitation, but future individual studies and reviews should follow more rigorous methodological standards in order to improve the quality of the evidence and provide guidelines for the use of exergames in motor rehabilitation.     

Spondylocostal dysostosis in a pregnancy complicated by confined placental mosaicism for tetrasomy 9p

The spondylocostal dysostoses (SCD) are a clinically and genetically heterogeneous group of disorders characterized by defects of vertebral segmentation and rib abnormalities. We report on the diagnosis of two siblings with SCD. Diagnosis was first made in a female infant following a pregnancy that was complicated by early fetal hydrops and a nuchal translucency of 8.2 mm in the first trimester. The clinical picture was complicated by the co-existent diagnosis of confined placental mosaicism (CPM) for tetrasomy 9p. To our knowledge, this is the first report of CPM for tetrasomy 9p. Postnatally the diagnosis of SCD was made on the basis of radiographic findings comprising multiple anomalies of the cervical and thoracic vertebrae and multiple fused and dysplastic ribs. Radiographic investigation of other family members showed that the infant's 4-year-old sibling had fusion of four ribs on the right side, indicating a less severe form of SCD. Testing of the genes DLL3, MESP2, and LFNG did not identify a mutation, suggesting that the siblings may have a new molecular subtype of SCD.     

T cell subset distributions following primary and secondary implantation at subcutaneous biomaterial implant sites

Synthetic biomaterials are considered to be nonimmunogenic. Therefore, the role that adaptive immunity may play in the host response to implanted synthetic biomaterials has not been extensively studied. Cardinal features of adaptive immunity include specificity and T cell responses, which are greater and more effective with upregulation of activation receptors upon rechallenge. We compared the primary and secondary in vivo host response to three synthetic biomaterials: Elasthane 80A, silicone rubber, and polyethylene terephthalate using a cage implant model in Sprague Dawley rats. The synthetic biomedical polymers were subcutaneously implanted in cages for 14 days. Following explantation of the cages and a 2 week healing period, rats were implanted with cages containing the biomedical polymers for an additional 2 weeks. The cellular exudates within the cages were analyzed 4, 7, and 14 days post primary and secondary implantation by flow cytometry for the following cell types: T cells (inclusive of CD8(+), CD4(+), and CD4(+)/CD25(+) subsets), B cells, granulocytes, and macrophages. At day 14 following secondary implantation, there was an increase in T cells, granulocytes, and macrophages in the exudates when compared with primary implantation for all groups inclusive of the empty cage control. However, CD4(+)/CD8(+) ratios, the percentage of CD4(+)CD25(+) T cells, and the macrophage surface adhesion/fusion did not vary significantly upon secondary implantation. Despite a quantitative increase in T cells following secondary biomaterial exposure, T cell subset distribution did not change, indicating nonspecific recruitment rather than an adaptive immune response.